STANFORD UNIVERSITY MEDICAL CENTER
Residency Training Program
Rotation Description
Rotation:
Nuclear Medicine
Rotation Duration:
4 weeks
Month(s):
4 months; no vacation permitted during these months
Institution:
Stanford and Palo Alto VA
Call Responsibility:
Senior night float (Fri, Sat)
Responsible Faculty Member(s):
Sanjiv Sam Gambhir MD, PhD, Chief
Michael L. Goris, MD, PhD
Andrei Iagaru, MD
I. Ross McDougall, MD, PhD
Erik Mittra, MD, PhD
Andrew Quon, MD
George Segall, MD
Minal Vasanawala, MD
Night(s):
Availability by pager
Location:
SUH Second Floor;
VA Building 1
Phone Numbers:
5-4717; 8-2414; 8-2415 (Stanford)
68870 (VA)
Technologists/Technical Staff:
Paulo Castaneda, CNMT
Christabel Chavez, CNMT
Elizabeth Farmer, CNMT
Christine Fujii, CNMT
Matthew Gabriele, CNMT
Nora Gurevich, Senior CNMT
Kent Hutchings, CNMT
NMTTP Director, VA Nuclear Medicine
Shawna Kinsella, CNMT
Julie Loero, CNMT, VA Nuclear Medicine
Luan Nguyen, CNMT
Jayesh Patel, CNMT
Nuclear Medicine Technical Manager
Lincoln Sanders, CNMT
Training Level:
R1 - R4
1

STANFORD UNIVERSITY MEDICAL CENTER
Residency Training Program
Rotation Description
Goals & Objectives
This rotation involves interpretation of a wide range of radionuclide imaging studies, functional radionuclide studies, SPECT, PET, PET-CT, and radiotherapy of thyroid disease. Residents will receive:

4 months of clinical, hands-on training in Nuclear Medicine working one on one with attending physicians at Stanford (3 months) and VA Palo Alto (1 month)
ROTATION ONE (Stanford)
Medical Knowledge
Goal
Residents must demonstrate knowledge of established and evolving biomedical, clinical, epidemiological, and social-behavioral sciences, as well as the application of this knowledge to patient care. Residents are expected to:

Learn about the instruments used for imaging in Nuclear Medicine

Learn about the safe handling of radioactive materials (Health Physics)

Understand the concept of ALARA

Learn the indications for common Nuclear Medicine procedures, including bone scans, V/Q lung scans, myocardial perfusion imaging

Learn the importance of avoiding mis-administrations by interviewing the patient, writing prescriptions for administration of radiopharmaceuticals (assisted by Nuclear Medicine residents and fellows) and ensuring the dose and radiopharmaceutical are appropriate

Learn about therapy using radionuclides, with attention to meeting the training requirements for the American Board of Radiology (involvement in treatment of 3 patients with less than
33 mCi of
131
I)

The role of Nuclear Medicine studies in Pediatrics will be introduced

The resident will observe interpretation of PET/CT scans

The resident will be observed for quality of interaction with patients, medical colleagues, technologists and ancillary staff, and referring physicians

Last week of the rotation will be a hands-on experience in the hot lab, shadowing the technologist in-charge of the daily operations
Patient Care
Goal
Residents must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. Residents are expected to:

Interpret the following types of nuclear radiology studies: bone, V/Q, hepatobiliary, GI
2

STANFORD UNIVERSITY MEDICAL CENTER
Residency Training Program
Rotation Description bleeding, thyroid, parathyroid and basic renal scans

Correlate findings with radiographs and other imaging studies and prescribe additional studies when appropriate,

Coordinate activities in the reading room, including providing direction for the technologists, consultation for other clinicians, and answering the phone,

Assist with radioactive therapy treatments, making sure the consent form is completed properly and that the appropriate dose is administered, giving particular attention to radiation safety practices during the procedure.

Assist specifically with three administrations of less than 33 mCi of
131
I

Develop a management plan based on nuclear medicine and radiology study findings and clinical information

Demonstrate proper technique in planning and performing nuclear medicine and radiology procedures
Professionalism
Goal
Residents must demonstrate a commitment to carrying out professional responsibilities and an adherence to ethical principles. Residents are expected to:

Demonstrate a responsible work ethic with regard to conference attendance and work assignments

Demonstrate acceptable personal demeanor and hygiene

Work with the health care team in a professional manner to provide patient- centered care.

Notify referring clinician for urgent, emergent, or unexpected findings, and document in dictation.
Interpersonal and Communication Skills
Goal
Residents must demonstrate interpersonal and communication skills that result in the effective exchange of information and teaming with patients, their families, and professional associates.
Residents are expected to:

Show sensitivity to and communicate effectively with all members of the health care team

Appropriately obtain informed consent

Recognize, appropriately communicate, and document in the patient record urgent or unexpected findings in the nuclear medicine study

Produce nuclear medicine reports that are accurate, concise, and grammatically correct

Effectively teach residents, medical students and other health care professionals
3

STANFORD UNIVERSITY MEDICAL CENTER
Residency Training Program
Rotation Description
Practice-Based Learning and Improvement
Goal
Residents must demonstrate the ability to investigate and evaluate their care of patients, to appraise and assimilate scientific evidence, and to continuously improve patient care based on constant selfevaluation and lifelong learning. Residents are expected to develop skills and habits to be able to:

Assess images for quality, identify sources of artifact, and suggest methods of improvement.

Demonstrate independent self-study using various resources including texts, journals, teaching files, and other resources on the internet, and

Facilitate the learning of students and other health care professionals.

Incorporate formative feedback into daily practice, positively responding to constructive criticism, and

Follow-up interesting or difficult cases without prompting and share this information with appropriate faculty and fellow residents.
Systems Based Practice
Goal
Residents must demonstrate an awareness of, and responsiveness to, the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide optimal health care. Residents are expected to:

Understand how their image interpretation affects patient care.

Demonstrate knowledge of and apply appropriateness criteria and other cost-effective healthcare principles to professional practice

Provide accurate and timely interpretations to decrease length of hospital and emergency department stay,

Appropriately notify the referring clinician if there are urgent or unexpected findings and document such without being prompted; and

Advocate for quality patient care in a professional manner, particularly concerning imaging utilization issues.
ROTATION TWO (Stanford)
Medical Knowledge

The resident will be educated further about the common and less commonly ordered diagnostic tests and will learn about dynamic studies of the urinary and gastro-intestinal tract

The role of
111
In and
99m
Tc white blood cell scan and
67
Gallium in patients with infection or abscess will be learned

The resident will be involved in the interpretation and reporting of PET/CT and learn normal variations and potential causes of false positive results
4

STANFORD UNIVERSITY MEDICAL CENTER
Residency Training Program
Rotation Description

The resident will be actively involved in the treatment of patients with hyperthyroidism using less than 33 mCi of
131
I

The resident will be expected to be involved in the interpretation of several diagnostic studies daily, presenting the patient history, indications and results of the study to the attending physician. The resident will be responsible for dictating and editing the report.

The resident will learn how radiopharmaceuticals are ordered, delivered and logged into the division

The resident will be observed for quality of interaction with patients, medical colleagues, technologists and ancillary staff and referring physicians.
Patient Care
Residents are expected to:

Read and/or dictate films with the assistance/review of the faculty radiologist.

Assist with radioactive therapy treatments, making sure the consent form is completed properly and that the appropriate dose is administered, giving particular attention to radiation safety practices during the procedure.

Recognize limitations of personal competency and ask for guidance when appropriate.
Professionalism
Goal
Residents must demonstrate a commitment to carrying out professional responsibilities and an adherence to ethical principles. Residents are expected to:

Demonstrate a responsible work ethic with regard to conference attendance and work assignments

Demonstrate acceptable personal demeanor and hygiene

Work with the health care team in a professional manner to provide patient- centered care.

Notify referring clinician for urgent, emergent, or unexpected findings, and document in dictation.
Interpersonal and Communication Skills
Goal
Residents must demonstrate interpersonal and communication skills that result in the effective exchange of information and teaming with patients, their families, and professional associates.
Residents are expected to:

Show sensitivity to and communicate effectively with all members of the health care team
5

STANFORD UNIVERSITY MEDICAL CENTER
Residency Training Program
Rotation Description

Appropriately obtain informed consent

Recognize, appropriately communicate, and document in the patient record urgent or unexpected findings in the nuclear medicine study

Produce nuclear medicine reports that are accurate, concise, and grammatically correct

Effectively teach residents, medical students and other health care professionals
Practice-Based Learning and Improvement
Goal
Residents must demonstrate the ability to investigate and evaluate their care of patients, to appraise and assimilate scientific evidence, and to continuously improve patient care based on constant selfevaluation and lifelong learning. Residents are expected to develop skills and habits to be able to:

Assess images for quality, identify sources of artifact, and suggest methods of improvement.

Demonstrate independent self-study using various resources including texts, journals, teaching files, and other resources on the internet, and

Facilitate the learning of students and other health care professionals.

Incorporate formative feedback into daily practice, positively responding to constructive criticism, and

Follow-up interesting or difficult cases without prompting and share this information with appropriate faculty and fellow residents.
Systems Based Practice
Goal
Residents must demonstrate an awareness of, and responsiveness to, the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide optimal health care. Residents are expected to:

Understand how their image interpretation affects patient care.

Demonstrate knowledge of and apply appropriateness criteria and other cost-effective healthcare principles to professional practice

Provide accurate and timely interpretations to decrease length of hospital and emergency department stay,

Appropriately notify the referring clinician if there are urgent or unexpected findings and document such without being prompted; and

Advocate for quality patient care in a professional manner, particularly concerning imaging utilization issues.
ROTATION THREE (Stanford)
Medical Knowledge

The resident will be actively involved with more of the diagnostic scans seen in the first and
6

STANFORD UNIVERSITY MEDICAL CENTER
Residency Training Program
Rotation Description second months and should become increasingly confident and competent in interpretation of all standard Nuclear Medicine diagnostic studies

The resident will learn the regulations for release of patients treated with radionuclides including doses larger than 33 mCi of
131
I

The trainee will learn how to interpret whole body scans with
123
I and
131
I

The role of Nuclear Medicine studies in Pediatrics will be expanded so the resident should be exposed to the majority of procedures they will encounter in practice

The resident will have 1 week of exposure to the daily practices in the hot lab, as part of the
Authorized User credentials (work day will start at 7:00 during this week). These activities include, but are not limited to: dose calibrator constancy/accuracy/linearity tests; survey meter check calibration; gamma camera quality control (intrinsic/extrinsic flood, center of rotation, uniformity); dose calibration; management of radioactive spills; surveying for contamination; the use of the
99m
Tc generator; preparation of
99m
Tc labeled MAA, MDP and
111
In labeled WBCs.

The residents will be required to attend the basic science lectures held every Thursday in the
Nuclear Medicine Clinic conference room (7:30-8:30)
Patient Care
Residents are expected to:

Read and/or dictate films with the assistance/review of the faculty radiologist.

Assist with radioactive therapy treatments, making sure the consent form is completed properly and that the appropriate dose is administered, giving particular attention to radiation safety practices during the procedure.

Recognize limitations of personal competency and ask for guidance when appropriate.
Professionalism
Goal
Residents must demonstrate a commitment to carrying out professional responsibilities and an adherence to ethical principles. Residents are expected to:

Demonstrate a responsible work ethic with regard to conference attendance and work assignments

Demonstrate acceptable personal demeanor and hygiene

Work with the health care team in a professional manner to provide patient- centered care.

Notify referring clinician for urgent, emergent, or unexpected findings, and document in dictation.
Interpersonal and Communication Skills
Goal
7

STANFORD UNIVERSITY MEDICAL CENTER
Residency Training Program
Rotation Description
Residents must demonstrate interpersonal and communication skills that result in the effective exchange of information and teaming with patients, their families, and professional associates.
Residents are expected to:

Show sensitivity to and communicate effectively with all members of the health care team

Appropriately obtain informed consent

Recognize, appropriately communicate, and document in the patient record urgent or unexpected findings in the nuclear medicine study

Produce nuclear medicine reports that are accurate, concise, and grammatically correct

Effectively teach residents, medical students and other health care professionals
Practice-Based Learning and Improvement
Goal
Residents must demonstrate the ability to investigate and evaluate their care of patients, to appraise and assimilate scientific evidence, and to continuously improve patient care based on constant selfevaluation and lifelong learning. Residents are expected to develop skills and habits to be able to:

Assess images for quality, identify sources of artifact, and suggest methods of improvement.

Demonstrate independent self-study using various resources including texts, journals, teaching files, and other resources on the internet, and

Facilitate the learning of students and other health care professionals.

Incorporate formative feedback into daily practice, positively responding to constructive criticism, and

Follow-up interesting or difficult cases without prompting and share this information with appropriate faculty and fellow residents.
Systems Based Practice
Goal
Residents must demonstrate an awareness of, and responsiveness to, the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide optimal health care. Residents are expected to:

Understand how their image interpretation affects patient care.

Demonstrate knowledge of and apply appropriateness criteria and other cost-effective healthcare principles to professional practice

Provide accurate and timely interpretations to decrease length of hospital and emergency department stay,

Appropriately notify the referring clinician if there are urgent or unexpected findings and document such without being prompted; and

Advocate for quality patient care in a professional manner, particularly concerning imaging utilization issues.
8

STANFORD UNIVERSITY MEDICAL CENTER
Residency Training Program
Rotation Description
ROTATION FOUR (Palo Alto VA Medical Center)
Medical Knowledge

The resident will be responsible for the interpretation and reporting of PET/CT and learn the most common indications for PET/CT, as well as Neurology and Cardiology applications

The resident should have received all necessary training to practice Nuclear Medicine in their future role as a consultant in Radiology
 The resident will continue to be observed for quality of interaction with patients, medical colleagues, technologists and ancillary staff and referring physicians
Patient Care
Residents are expected to:

Read and/or dictate films with the assistance/review of the faculty radiologist.

Assist with review of cases to be presented at tumor boards

Recognize limitations of personal competency and ask for guidance when appropriate.
Professionalism
Goal
Residents must demonstrate a commitment to carrying out professional responsibilities and an adherence to ethical principles. Residents are expected to:

Demonstrate a responsible work ethic with regard to conference attendance and work assignments

Demonstrate acceptable personal demeanor and hygiene

Work with the health care team in a professional manner to provide patient- centered care.

Notify referring clinician for urgent, emergent, or unexpected findings, and document in dictation.
Interpersonal and Communication Skills
Goal
Residents must demonstrate interpersonal and communication skills that result in the effective exchange of information and teaming with patients, their families, and professional associates.
Residents are expected to:

Show sensitivity to and communicate effectively with all members of the health care team
9

STANFORD UNIVERSITY MEDICAL CENTER
Residency Training Program
Rotation Description

Appropriately obtain informed consent

Recognize, appropriately communicate, and document in the patient record urgent or unexpected findings in the nuclear medicine study

Produce nuclear medicine reports that are accurate, concise, and grammatically correct

Effectively teach residents, medical students and other health care professionals
Practice-Based Learning and Improvement
Goal
Residents must demonstrate the ability to investigate and evaluate their care of patients, to appraise and assimilate scientific evidence, and to continuously improve patient care based on constant selfevaluation and lifelong learning. Residents are expected to develop skills and habits to be able to:

Assess images for quality, identify sources of artifact, and suggest methods of improvement.

Demonstrate independent self-study using various resources including texts, journals, teaching files, and other resources on the internet, and

Facilitate the learning of students and other health care professionals.

Incorporate formative feedback into daily practice, positively responding to constructive criticism, and

Follow-up interesting or difficult cases without prompting and share this information with appropriate faculty and fellow residents.
Systems Based Practice
Goal
Residents must demonstrate an awareness of, and responsiveness to, the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide optimal health care. Residents are expected to:

Understand how their image interpretation affects patient care.

Demonstrate knowledge of and apply appropriateness criteria and other cost-effective healthcare principles to professional practice

Provide accurate and timely interpretations to decrease length of hospital and emergency department stay,

Appropriately notify the referring clinician if there are urgent or unexpected findings and document such without being prompted; and

Advocate for quality patient care in a professional manner, particularly concerning imaging utilization issues.
PROFESSIONALISM AND PATIENT CARE WORKFLOW AND DUTIES
APPLICABLE TO ALL NUCLEAR MEDICINE ROTATIONS:

The resident has primary responsibility for individual patient diagnostic studies, which includes obtaining history, choice of procedure, administration of radiopharmaceutical,
10

STANFORD UNIVERSITY MEDICAL CENTER
Residency Training Program
Rotation Description performance of the study, interpreting the study, and reporting the study

Residents formally review patient studies with the faculty at daily conferences which are also clinical teaching sessions

The resident who starts a study must ensure completion of all aspects of the study including interpretation, dictating, editing and signing the report
 Review inpatients’ requests and ensure requisitions are completed

Discuss the study with the patient and ensure that the radiopharmaceutical dose is correct

Administer the radiopharmaceutical and countersign the dose slip insuring that the correct patient has been given the correct dose of the correct radiopharmaceutical.

Place short handwritten note in chart of all inpatients

Communicate all urgent results directly to the referring physician
Conference Schedule/Format
Title
Clinical Journal Club
Nuclear Medicine Grand Rounds
Case review
Resident conference
Day
Monday
Tuesday
Wednesday
Friday
Time
12:15 PM
7:30 AM
12:15 AM
7:30 AM
Method of Assessment of Performance:

Written evaluation of resident by faculty members monthly

Verbal feedback to resident by faculty

Case log of I 131 administrations

ACR In-Training Service Exam annually
Location
H2200
Clark S360
H2200
H2200
Recommended Reading

Nuclear Medicine: The Requisites (Thrall)

Essentials of Nuclear Medicine (Mettler)
11

STANFORD UNIVERSITY MEDICAL CENTER
Residency Training Program
Rotation Description
APPENDIX:
NUCLEAR MEDICINE CORE CURRICULUM, FROM RAD PRIMER
Pre-call
1 Acute Acalculous Cholecystitis
2 Acute Calculous Cholecystitis
3 Acute Rejection
4 ATN
5 Biliary Bypass Obstruction
6 Biliary Leak
7 Brain Death
8 Cellulitis
9 CSF Leak
10 Fracture
11 GI Bleeding Localization
12 Meckel Diverticulum
13 Myocardial Infarction
14 Myocardial Ischemia
15 Obstructive Uropathy
16 Osteomyelitis, Appendicular
17 Osteomyelitis, Axial
18 Osteomyelitis, Feet
19 Renal Transplant
20 V/Q, Pulmonary Embolism
Musculoskeletal
Benign Bone Tumors
21 Osteoid Osteoma
Malignant Bone Tumors
22 Skeletal Metastases
23 Superscan
24 Osteosarcoma
25 Ewing Sarcoma
26 Prostate Cancer, Bone Metastases
Therapy
Infection
27 Osteomyelitis, Temporal Bone
Metabolic Bone Disease
28 Hyperparathyroidism
29 Hypertrophic Osteoarthropathy
12

STANFORD UNIVERSITY MEDICAL CENTER
Residency Training Program
Rotation Description
Dysplasias
30 Paget Disease
31 Fibrous Dysplasia
32 Melorheostosis
33 Multiple Enchondromatoses
Avascular Necrosis
34 Osseous Necrosis
35 Legg-Calve Perthes Disease
Surgical Assessment
36 Joint Prostheses, Painful
37 Failed Back Surgery Syndrome
Skeletal Trauma
38 Insufficiency Fracture
39 Trauma, Non-Accidental
40 Stress Fracture
41 Stress Reaction, Bone
Regional Pain Evaluation
42 Complex Regional Pain Syndrome
43 Arthritis, Non-Infectious
Skeletal Muscle and Soft Tissues
Bone Marrow Disorders
44 Heterotopic Ossification
45 Amyloidosis
46 Hematoproliferative Disorders
47 Sickle Cell Disease, Bone Pain
Vascular and Lymphatics
Lymphatic
48 Lymphedema
49 Sentinel Lymph Node Mapping
Vascular
50 Vascular Graft Infection
Cardiovascular
Cardiac
51 Myocardial Viability
Chest and Mediastinum
Lung Ventilation and Perfusion Abnormalities
Lung Infection and Inflammation
52 Aspiration (Salivagram)
53 PCP, AIDS-related
54 Granulomatous Disease
Lung Cancer
55 Kaposi Sarcoma
13

STANFORD UNIVERSITY MEDICAL CENTER
Residency Training Program
Rotation Description
Pleura
Mediastinum
56 Solitary Pulmonary Nodule
57 Non-Small Cell Lung Cancer
58 Metastases, Lungs & Mediastinum
59 Pleural Disease, Malignant & Inflammatory
Central Nervous System
Vascular Assessment
Seizure Assessment
60 Seizure Evaluation
Dementia and Neurodegenerative
61 Alzheimer Disease
Neurooncology
62 Radiation Necrosis vs. Recurrent Tumor
Benign Brain Tumors
63 Pituitary Adenoma
CSF Imaging
64 Normal Pressure Hydrocephalus
65 Ventricular Shunt Dysfunction
Miscellaneous
66 Heterotopic Gray Matter
67 Brain Infection & Inflammation
Head and Neck
Squamous Cell Carcinoma of the Head and Neck
68 SCCHN, Staging
69 SCCHN, Primary Unknown
70 SCCHN, Therapeutic Assessment/Restaging
Miscellaneous Primary Head and Neck Tumors
71 Parotid and Salivary Tumors
72 Neuroendocrine Tumors, Head & Neck
73 Warthin Tumor
Miscellaneous
74 Lacrimal Complex Dysfunction
Thyroid/Parathyroid
Parathyroid
75 Parathyroid Adenoma, Typical
76 Parathyroid Adenoma, Ectopic
Hyperthyroidism
77 Steatosis, Liver
78 Hashimoto Thyroiditis
79 Multinodular Goiter
80 Thyroid Adenoma, Hyperfunctioning
14

STANFORD UNIVERSITY MEDICAL CENTER
Residency Training Program
Rotation Description
81 Subacute Thyroiditis
Thyroid, Benign Miscellaneous
Thyroid Cancer
82 Ectopic Thyroid
83 Congenital Hypothyroidism
84 Well-Differentiated Thyroid Cancer
85 Well-Differentiated Thyroid Cancer, PET
Gastrointestinal
Biliary
86 Chronic Cholecystitis
87 Biliary Atresia
88 Common Bile Duct Obstruction
89 Choledochal Cyst
Hepatic
90 Focal Nodular Hyperplasia
91 Steatosis, Liver
92 Hypersplenism
93 Cavernous Hemangiomas
Adrenal
94 Adrenal Malignancy
95 Pheochromocytoma
96 Neuroblastoma
Spleen
97 Accessory & Ectopic Splenic Tissue
98 Asplenia/Polysplenia Syndromes
Oropharynx and Esophagus
99 Esophageal Cancer
Stomach
100 Gastric Emptying Disorders
101 Gastric Carcinoma
Intestine
102 Intestinal Cancer, Therapy Eval./Restaging
103 Intestinal Cancer, Primary and Staging
Pancreas
104 Pancreatic Adenocarcinoma
Miscellaneous
105 Intraabdominal Infection
106 Carcinoid Tumor
107 GI Stromal Tumors
108 Peritoneal Systemic Shunt Evaluation
109 Diaphragmatic Patency Determination
Genitourinary
15

STANFORD UNIVERSITY MEDICAL CENTER
Residency Training Program
Rotation Description
Kidney
110 Chemotherapy Effect
111 Renal Ectopy
112 Renovascular Hypertension
113 Acute Renal Failure
114 Pyelonephritis
115 Renal Cortical Scar
Collecting System
116 Reflux Uropathy
Testes
Ovaries
117 Testicular Torsion
118 Testicular Cancer
Uterus
119 Uterus, Normal & Benign Pathology
120 Cervical Cancer
121 Endometrial Cancer
Prostate
122 Prostate Cancer, Antibody Scan
Oncology, Other
Lymphoma
123 Lymphoma, Benign Mimics
124 Hodgkin Lymphoma Staging
125 Lymphoma Post-Therapy Evaluation
126 Non-Hodgkin Lymphomas, Low Grade
127 Non-Hodgkin Lymphoma Staging
Melanoma
128 Melanoma Staging
129 Melanoma Therapy Eval./Restaging
Breast Cancer
130 Breast Cancer, Primary
131 Breast Cancer, Staging/Restaging
Miscellaneous
132 Adenocarcinoma of Unknown Primary
133 Paraneoplastic Disorders
16